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A Conversation on Management of Dysphagia. A Supplementary Training Module for Swallowing Screening Teams based on the booklet titled “Management of Dysphagia In Acute Stroke: An Educational Manual for the Dysphagia Screening Professional”. Acknowledgements.

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slide1

A Conversation on Management of Dysphagia

A Supplementary Training Module for Swallowing Screening Teams based on the booklet titled “Management of Dysphagia In Acute Stroke: An Educational Manual for the Dysphagia Screening Professional”

acknowledgements
Acknowledgements

The Heart and Stroke Foundation of Ontario is grateful to the following professionals for their work in developing this CD:

Rosemary Martino, MA, MSc, PhD

Associate Professor, University of Toronto

Donelda Moscrip, MSc

Regional Stroke Rehabilitation Coordinator

Central East Stroke Network

Alane Witt-Lajeunesse, MS, MSc

Dysphagia Educator/Coordinator

Chinook Rehabilitation Program

Patricia Knutson, MA

Speech Language Pathologist,

Huron Perth Healthcare Alliance

Becky French, MSc

Speech Language Pathologist,

Southlake Regional Health Centre

Audrey Brown, MSc

Speech Language Pathologist,

Providence Care, St. Mary's of the Lake Hospital

Laura MacIsaac, BScN, MSc

Stroke Specialist Case Manager

Stroke Strategy Southeastern Ontario

Anna Mascitelli, MA

Speech Language Pathologist,

Niagara Health System

agenda
Agenda
  • Dysphagia and Stroke Care
  • Best Practice Guidelines for Managing Dysphagia
  • Swallowing: Anatomy, Physiology, Pathophysiology
  • Clinical Approach to Dysphagia
  • Case Studies
slide4

Source: Heart & Stroke Foundation (2006) Management of Dysphagia in Acute Stroke: An Educational Manual for the Dysphagia Screening Professional, 18

best practice guidelines for managing dysphagia
Best Practice Guidelines for Managing Dysphagia
  • Maintain all acute stroke survivors NPO until swallowing ability has been determined.
  • Screen all stroke survivors for swallowing difficulties as soon as they are awake and alert.
  • Screen all stroke survivors for risk factors for poor nutritional status within 48 hours of admission.
best practice guidelines for managing dysphagia6
Best Practice Guidelines for Managing Dysphagia
  • Assess the swallowing ability of all stroke survivors who fail the swallowing screening.
  • Provide feeding assistance or mealtime supervision to all stroke survivors who pass the screening.
  • Assess the nutrition and hydration status of all stroke survivors who fail the screening.
best practice guidelines for managing dysphagia7
Best Practice Guidelines for Managing Dysphagia
  • Reassess all stroke survivors receiving modified texture diets or enteral feeding for alterations in swallowing status regularly.
  • Explain the nature of the dysphagia and recommendations for management, follow-up and reassessment upon discharge to all stroke survivors, family members and care providers.
best practice guidelines for managing dysphagia8
Best Practice Guidelines for Managing Dysphagia
  • Provide the stroke survivor or substitute decision maker with sufficient information to allow informed decision making about nutritional options.
anatomy and physiology of swallowing
Anatomy and Physiology of Swallowing

Source: Heart & Stroke Foundation (2006) Management of dysphagia in acute stroke: an educational manual for the dysphagia screening professional, p. 8

4 stages of swallowing
4 Stages of Swallowing
  • Oral Preparatory Stage

Source: Heart & Stroke Foundation (2002) Improving Recognition and Management of Dysphagia in Acute Stroke: a Vision for Ontario, p. 9

4 stages of swallowing11
4 Stages of Swallowing
  • Oral Propulsive Stage

Source: Heart & Stroke Foundation (2002) Improving Recognition and Management of Dysphagia in Acute Stroke: a Vision for Ontairo, p. 9

4 stages of swallowing12
4 Stages of Swallowing

3. Pharyngeal Stage

Source: Heart & Stroke Foundation (2002) Improving Recognition and Management of Dysphagia in Acute Stroke: a Vision for Ontairo, p. 9

4 stages of swallowing13
4 Stages of Swallowing

4. Esophageal Stage

Source: Heart & Stroke Foundation (2002) Improving Recognition and Management of Dysphagia in Acute Stroke: a Vision for Ontairo, p. 9

normal swallowing changes in the elderly
Normal Swallowing Changes in the Elderly
  • Normal Changes
    • Reduction in muscle tone
    • Loss of elasticity of connective tissue
    • Decreased saliva production
    • Changes in sensory function
    • Decreased sensitivity of mucosa
  • Healthy elderly individuals can compensate
  • Compounded by fatigue or weakness from disease processes (e.g. stroke) leading to dysphagia
what is dysphagia
What is Dysphagia?
  • Difficulty or discomfort in swallowing
  • Can occur with any motor, sensory or structural changes to the swallowing mechanism
  • Dysphagia affects a person’s ability to eat or drink safely.
types of dysphagia
Types of Dysphagia
  • Oral Dysphagia
  • Pharyngeal Dysphagia
  • Esophageal Dysphagia
complications of dysphagia
Complications of Dysphagia

Health Issues:

  • Aspiration pneumonia
  • Malnutrition
  • Dehydration
  • Mortality

Health Care Costs:

  • Length of Stay
  • Increased workload for staff
dysphagia risk factors
Dysphagia Risk Factors
  • Stroke location
    • Cerebral hemisphere
    • Brainstem
  • Comorbid conditions
    • Progressive Neurologic
    • Neuromuscular disorder
    • Respiratory disorder
    • Systemic disorder…
  • Medications
    • Side effects
      • Tardive dyskinesia
      • Xerostomia
  • Tracheotomy and Ventilation
interdisciplinary team
Interdisciplinary Team
  • Speech-Language Pathologist
  • Registered Dietitian
  • Physician
  • Registered Nurse / Registered Practical Nurse
  • Occupational Therapist
  • Physiotherapist
  • Pharmacist
  • Stroke Survivor, Family and Care Providers
dysphagia screening tool
Dysphagia Screening Tool
  • Identifies patients at risk for dysphagia
  • Pass / Fail measure
  • Must be proven reliable and valid
  • Initiates early referral for assessment, management or treatment for those at higher risk
dysphagia assessment
Dysphagia Assessment
  • Completed by SLP dysphagia expert
  • Determines the structure, function, and degree of impairment
  • Various types of assessment:
    • Clinical Bedside
    • Instrumental
  • Directs treatment plan
nutrition screening and assessment
Nutrition Screening and Assessment
  • Best Practice Guidelines recommend:
    • Nutrition screening within 48 hours of admission
    • Those who fail are referred to an RD
    • See booklet from Heart & Stroke Foundation of Ontario (2005) “Management of Dysphagia in Acute Stroke: Nutrition Screening for Stroke Survivors”
ongoing monitoring
Ongoing Monitoring
  • Clinical indicators of possible dysphagia
    • Poor dentition
    • Drooling
    • Asymmetric facial and lip weakness
    • Changes in voice
    • Dysarthria - slurred speech
    • Reduced tongue movement
    • Coughing or choking

Please see page 24 of manual for complete list

dysphagia management
Dysphagia Management
  • Oral hygiene
  • Restriction of diet textures
  • Feeding strategies
  • Therapeutic and postural interventions
  • Ongoing education and counseling
case study 1
Case Study #1

RS is a 71-year-old male who was admitted to hospital with right-sided weakness and garbled speech. RS was accompanied to hospital by his wife of 50 years, and she provided medical and social histories. His medical history includes Parkinson’s disease (1998), transurethral radical prostatectomy (1996) and appendectomy (remote). Mr. and Mrs. S have six children and 23 grandchildren, mostly living nearby. RS worked as an electrician for 40 years and recently worked as a clerk in the local farmers’ supply store for 3 years until his Parkinson’s symptoms became pronounced.

case study 1 cont d
Case Study #1 (cont’d)

On admission, blood pressure was 166/78 mmHg, pulse was 82 bpm and SaO2 was 92%. Right visual field neglect was identified, and right facial asymmetry and dense right-sided paresis in the arm and leg were present. Tremors were present on the left side. Unintelligible speech and drooling were noted. Mr. S was wearing glasses, a hearing aid in the right ear and dentures when he was admitted. A computed tomography (CT) scan performed in the emergency department demonstrated a lacunar infarct in the left periventricular white matter. Electrocardiography (ECG) showed atrial fibrillation. Chest radiography is pending.

case study 1 rs
Social History

71 year old male

Married 50 years

6 children, 23 grandchildren

Electrician 40 years

Clerk in local farmer’s supply store

Medical History

Parkinson’s disease

TURP

Appendectomy

Medical History (continued)

Glasses

Right hearing aid

Dentures

Hx of Presenting Illness

Hospital arrival with wife

Right-sided weakness

Garbled speech

Case Study #1 - RS
case study 1 rs29
Assessment Results

On admission

blood pressure 166/78 mmHg

pulse was 82 bpm

SaO2 was 92%

Right visual neglect

Right facial asymmetry

Dense right-side paresis in arm and leg

Tremors on left side

Unintelligible speech and drooling

CT scan showed lacunar infarct in left periventricular white matter

ECG showed A-fib

Chest radiography pending

Case Study #1 - RS
case 1 discussion
Case #1 - DISCUSSION

What are the most immediate concerns for this individual?

case 1 discussion31
Case#1 - DISCUSSION

As a member of the interdisciplinary dysphagia team, what is your role?

case 1 discussion32
Case #1 - DISCUSSION

Briefly describe how you should respond to the swallowing needs of this individual.

case study 2
Case Study #2

DL is a 66-year-old male who presented in the emergency department after collapsing at home while digging in the garden. His wife found him unable to move his right arm or leg and unable to speak. A CT scan performed in the emergency department detected an early left middle cerebral artery (MCA) infarct. Echocardiography found a moderately enlarged left ventricle with grade II left ventricular systolic function but no clots and an elevated right ventricular systolic pressure of 88 mmHg. DL was obtunded, with no gag reflex, left deviation of the eyes, and intermittent consciousness.

case study 2 cont d
Case Study #2 (cont’d)

DL had not seen a doctor in 15 years. Previously, he had been independent and in good health, with no history of hypertension, diabetes, hypercholesterolemia or hospitalization. He did not take any medications and had stopped smoking 18 years ago. DL lives with his wife and three children. Family members accompanied him to the hospital, and they are very anxious. DL has now been in the emergency department for two hours. His family members want him to be fed and given medication for pain, as they believe he is in pain.

case study 2 dl
Social History

66-year-old male

Lives with his wife and three children

Medical History

Previously independent and in good health

NO history of:

Hypertension

Diabetes

Hypercholesterolemia

Hospitalization (has not seen a doctor in 15 years)

Medical History (continued)

Ex-smoker (18 yrs. ago)

No medication

Hx of Presenting Illness

Found by wife after collapsing at home while digging in the garden

Family members accompanied him to the hospital

Case Study #2 - DL
case study 2 dl36
Assessment Results

CT scan - early left MCA infarct

Echo

moderately enlarged left ventricle with grade II left ventricular systolic function

no clots

elevated right ventricular systolic pressure of 88 mmHg.

Unable to move right arm or leg

Unable to speak

No gag reflex

Left deviation of the eyes

Current Status

Obtunded

Intermittent consciousness

Family are very anxious

DL has been in emergency for 2 hours

Family members want him to be fed and given medication for pain, as they believe he is in pain.

Case Study #2 - DL
case 2 discussion
Case #2 - DISCUSSION

Based on best practice guidelines for dysphagia, how will the dysphagia screening process take place for this individual?

  • Who will start the process?
  • What will or will not be done?
  • When will it occur?
  • Where will it happen?
case 2 discussion38
Case #2 - DISCUSSION

Think of the best way to address the family’s concerns.

case study 3
Case Study #3

HN is an 85-year-old female who presented in the emergency department after a fall at home. She presents with left-sided weakness, decreased pain and temperature sensation, facial droop, slurred speech, dry mucous membranes, an intact gag reflex, cuts and abrasions and confusion. Until the event, HN had been independent and lived alone.

Previous medical history includes steroid- dependent rheumatoid arthritis, primarily affecting hands, knees and hips, atrial fibrillation and type 2 diabetes mellitus.

case study 3 cont d
Case Study #3 (cont’d)

Her family reports she has lost weight over the past six months, although she had not been dieting. In the emergency department, her daughter gave HN orange juice, as she thought her blood sugar may have been getting low. Her daughter reported that she began to sputter and choke when she attempted to swallow the juice. A CT scan shows a right-hemisphere infarct. Chest radiography shows pneumonia in the right upper lobe. HN has been in the emergency department now for two hours.

case study 3 hn
Social History

85-year-old female

Lived alone

Independent

Medical History

Steroid-dependent rheumatoid arthritis (hands, knees and hips)

Atrial fibrillation

Medical History (continued)

Type 2 diabetes mellitus

Weight loss over the past six months – unintentional

Hx of Presenting Illness

fell at home

Case Study # 3 - HN
case study 3 hn42
Assessment Results

left-sided weakness

decreased pain & temperature sensation

facial droop

slurred speech

dry mucous membranes

intact gag reflex

cuts, abrasions & confusion

CT Scan - right-hemisphere infarct

CXR - pneumonia in the right upper lobe

Current Status

Daughter gave orange juice - sputtered and choked

In emergency department now for two hours

Case Study # 3 - HN
case 3 discussion
Case #3 - DISCUSSION

Based on best practice guidelines for dysphagia, how will the dysphagia screening process take place for this individual?

  • Who will start the process?
  • What will or will not be done?
  • When will it occur?
  • Where will it happen?
case 3 discussion44
Case #3 - DISCUSSION

Think of the best way to address HN’s diabetic medical status in light of current swallowing difficulties.

case 3 discussion scenario
Case #3 – DISCUSSION-Scenario

When screened in the emergency department by a swallowing screening team member, NH failed the swallowing screen. She was kept NPO and referred to SLP for a swallowing assessment. The SLP saw HN for a bedside/clinical swallowing assessment. SLP recommendations after the assessment were:

  • pureed and honey thick fluid diet consistency,
  • no thin fluids
  • PO meds crushed with applesauce (check with pharmacist before crushing any meds)
  • VFSS also recommended.

You are the RN/RPN on shift when NH is transferred to medicine.

case 3 discussion scenario46
Case #3 – DISCUSSION-Scenario

What information regarding HN’s dysphagia could you provide to the receiving RN?

case 3 discussion scenario47
Case #3 – DISCUSSION-Scenario

What can be given to her if she has low blood sugar as per the RD/SLP?

case 3 discussion scenario48
Case #3 – DISCUSSION-Scenario

What are the pros and cons for giving thickened liquids for this patient?

case 3 discussion scenario49
Case #3 – DISCUSSION-Scenario

NH becomes agitated and demands water. (Diabetics often have an increased desire for water.)

How would you address her demand and family concerns?

case 3 discussion scenario50
Case #3 – DISCUSSION-Scenario

Given NHs post-stroke deficits what might you notice when assisting her with feeding?